Training on prevention of violence against women
in the medical curriculum at the University of Ibadan, Nigeria

1 Department of Epidemiology and Medical
Statistics, Faculty of Public Health, College of Medicine,
University of Ibadan, Nigeria

2 Department of Clinical Cognition, Nelson R
Mandela School of Medicine, University of KwaZulu-Natal,
Durban, South Africa

3 Department of Community Medicine, College
of Medicine, University of Ibadan

Corresponding author: O I Fawole (fawoleo@ymail.com)

Objectives. To determine the
knowledge and skills of final-year medical students in managing
victims of violence against women (VAW), and to describe the
extent to which VAW is included in the undergraduate curriculum
of the College of Medicine, University of Ibadan.

Method. A mixed-method study design
was used that collected qualitative data through a review of
curriculum documents and interviews of departmental heads (or
their representatives) of 6 departments in the college. A
semi-structured, self-administered questionnaire was used to
collect quantitative data from 109 final-year students.

Results. The response rate was 85.1%
and respondents’ mean age was 25.2±3.1 years. Physical, sexual,
psychological and economic abuse was found by 73.8%, 72.6%,
54.8% and 44.0% respectively, of the students. Most students
(77.4%) felt it was part of their duty to ask patients about
abuse. Students with previous training about violence were more
likely to be knowledgeable (odds ratio (OR) 1.64; 95% confidence
interval (CI) 0.61 - 4.42) and skilled (OR 1.27; 95% CI 0.53 -
3.05). Men had better knowledge and skills than women. VAW was
not included as a topic in the curriculum.

Conclusion. Most students were
willing to ask patients about abuse but lacked the fundamental
knowledge and skills to do so. Faculty at the college agreed to
review the curriculum to improve students’ knowledge and
management skills regarding VAW.

AJHPE 2013;5(2):75-79. DOI:10.7196/AJHPE.222

Violence against women (VAW) has become a major public health
and human rights issue. This social evil occurs in all
countries, irrespective of social, economic, religious and
cultural traditions. Notably, the increasing incidence of
battering, rape, domestic violence, honour killings, human
trafficking, prostitution, forced and early marriages, female
genital mutilation and sexual slavery was noted by the
Secretary-General of the United Nations, at the 4th World
Conference on Women.1

Deeply rooted African tradition and culture have been blamed
for most of the physical and psychological customs that
perpetuate VAW.2
To illustrate, wife-beating is perceived as normal in African
marital relationships,3,4 and the custom of
inheriting a woman as part of her deceased husband’s estate has
left many women poor, homeless and vulnerable to abuse. While
most African countries have amended or passed gender-sensitive
laws to stem the tide of violence and prejudice against women,
concern remains over the lack of enforcement of such legislation5 in a
region characterised by widespread armed conflict, poverty and
social inequality, which result in continued exploitation and
abuse of vulnerable groups.2,6

Results of the Demographic and Health Survey in Nigeria of 2008
indicated that 28% of women aged 15 - 49 years had experienced
physical violence since the age of 15, and that 15% had
experienced physical violence in the 12 months prior to the
survey.7
Epidemiological evidence suggests that VAW affects the health
and wellbeing of women in many ways, resulting in fatal
(homicide, suicide and AIDS-related deaths) and non-fatal
(physical injury, chronic pain syndromes and gastro-intestinal
disorders) outcomes.8 Physical and sexual violence
further affects the mental health of victims, and has resulted
in behavioral outcomes such as alcohol and/or drug abuse and
high sexual risk-taking behavior.8

Evidence suggests that women are likely to disclose intimate
partner violence to healthcare practitioners,7 but the
latter's inadequate training may leave them unable to recognise
or, where disclosed, unable to respond to victims of abuse.
Concern has also been raised about reports9 of women
suffering abuse or neglect at the hands of healthcare
practitioners and the perceived reluctance of health personnel
to discuss physical and sexual violence with patients who
disclose being in violent relationships.8

Medical schools with gender-based violence curricula have
played an important part in the promotion of good maternal and
child health outcomes. Research indicates that physicians
trained in VAW are significantly more likely to screen for signs
of abuse.10
There is also increasing debate about the efficacy of curricular
approaches and the most effective educational techniques to be
used for training.11

Realising the central role of medical schools in preparing a
future generation of practitioners and citizens, there is
consequently a need to educate medical students about the
treatment, referral system and impact of VAW when managing
victims. However, little research is done in the African context
about the prior experiences of medical students of VAW and their
attitudes to treating victims of abuse. The present study was
therefore conducted to determine perceptions and the level of
competence (knowledge, skills) to manage victims of VAW among
the final-year student cohort and the extent to which the topic
is taught in the College of Medicine at the University of
Ibadan, Nigeria.

Method

The College of Medicine trains medical and dental students. It
includes a 950-bed tertiary health facility − the University
College Hospital. Medical students rotate through the Faculty of
Public Health in their 3rd, 4th and 5th years of study. Students
similarly rotate for periods of approximately 6 - 8 weeks
through each of the 6 clinical blocks in their final year.

A mixed methods approach was used in this descriptive,
analytical cross-sectional study. Quantitative data was
collected through a self-administered questionnaire that
collected data on students’ knowledge of VAW, factors
influencing their acquisition of knowledge and skills, and the
extent to which they had prior training on the topic. The final
part of the questionnaire explored students’ perceptions and
attitudes towards abusers and victims, their levels of empathy
for those in abusive relationships, and their skills in managing
abused patients.

Final-year medical students (N=128)
in their 5th year of study constituted the primary
respondents, while faculty members were the secondary
respondents. Faculty members included staff responsible for
bedside teaching and lecturing from Family Medicine,
Paediatrics, Obstetrics and Gynaecology, Accidents and Trauma,
Dentistry and Public Health.

A qualitative data analysis of curriculum documents including
module and course information on the Bachelor of Medicine and
Bachelor of Surgery (MB BS) course were undertaken. In-depth
interviews were also conducted with key faculty informants from
each of the 6 departments to verify the extent of coverage of
VAW in the curriculum. The questions explored included the
availability of a programme on VAW, content covered, teaching
methods, competencies of trainers, and suggestions to improve
students’ competence concerning VAW.

The questionnaire was adapted from previous studies.12,13 Apilot study
was conducted with 20 students enrolled in their 4th year of
study at the school. Each questionnaire took about 20 minutes to
complete. The questionnaire was amended to improve clarity and
reduce ambiguity. A copy can be obtained from the corresponding
author.

The qualitative data were transcribed, cleaned and coded, and
themes identified. Descriptive analysis, frequencies, means and
standard deviations were performed on the data, using
statistical software STATA 11.0. Bivariate analysis using the
chi-squared (χ2) test was used to determine the
associations between variables. Significant variables in the
bivariate analysis were entered into a logistic regression model
to determine the strength of the associations. P-values <0.05 were considered
significant.

Ethical clearance for the study was obtained from the Joint
University of Ibadan/University College Hospital Institutional
Review Board (UI/EC/11/0103).

Results

Demographic data

A hundred-and-nine students (N=128;
85.1%) participated in the study. The mean age of the primary
respondents ranged from 16 to 39 years with a median age of 24
years. Most students were male (59.6%), and 73.4% were from the
Yoruba ethnic group.

Awareness of VAW

Seventy-seven per cent of the respondents indicated an
awareness of VAW. Their descriptions of the term varied, e.g.
the maltreatment of either sex, violence to women, physical
assault, beating and/or battery, and forms of physical, sexual
and psychological (mental) violence.

Knowledge of VAW

Physical violence.Most respondents (73.8%) could give
at least one correct example of a physically violent act.
Physical violence was described as beating (46.4%) and slaps
(15.5%).

Sexual violence.About three-quarters (72.6%) of the respondents gave at
least one correct example of a sexually violent act, while 11.9%
gave 2 or more examples. Sexual violence was mostly (67.8%)
described as rape.

Psychological violence.Slightly more than half (54.8%) gave
an example of a psychologically violent act, while 6% mentioned
2 correct examples. Psychological violence was described as
verbal abuse and insults (32.1% and 7.1% respectively).

Economic violence.Economic violence was described as
financial deprivation (17.9%), not allowing a woman to work
(14.3%), and lack of care (5.9%). Respondents’ knowledge of what
an act of economic violence comprised was stated by 44%; 5%
could mention 2 such acts.

Signs and symptoms suggestive of VAW.Complaints of aches and pains were
made by 90.4%. Students also mentioned other symptoms including
abortions (86.9%), fractures (78.6%), sexually transmitted
infections (66.7%) and headache (66.7%).

Perceptions of VAW

Magnitude of VAW. Regarding the
attitudes of students as indicated in Table 1, most of the
student respondents perceived VAW to be a common problem in
their environment. Fifty-two respondents (61.9%) thought it was
common (experienced by 10% of the
population) while 26.2% thought it was very
common (experienced by 15% of the population). Only
11.9% believed it was rare
(experienced by <5% of the population).

Asking patients about VAW.Most (77.4%) students regarded it as
part of their duty as physicians to enquire about violence, and
many (67.9%) were willing to do so. Those who were not willing
to engage with patients thought that it would intrude on the
private life of their patients (57.1%), and some students
(42.9%) believed it would be demeaning to enquire about VAW.

Students’ confidence about discussing the
topic with patients.Student
responses varied on the extent to which they were confident
about asking patients about VAW. Eighty-one per cent were very confident to ask about depression,
73.8% were very confident to ask
about beatings, and 54.8% were very
confident to ask about rape. Thirty-six per cent
reported little confidence to ask
about rape, while 9% were not confident
at all to enquire about any aspect of the topic.

Attitude towards victims. Less than
half (44.0%) of respondents indicated that they would be
sympathetic towards a woman who chose to remain in a violent
relationship, while 48.8% felt that the abused victim did not
deserve the experience and that violence was wrong.

Skills and competencies

Most respondents indicated not being very
skilled to treat victims of violence. For instance,
only 14.3% stated that they were very
skilled and could detect the warning signs and symptoms
of VAW. Less than 10% (9.5%) of the respondents reported being very skilled at treating and providing
medical care to victims, and 57% admitted to having some skill to do so.

Knowledge, attitude, confidence and
competence scores

Knowledge, attitude,
confidence and competence scores were awarded by giving one
mark for every correct statement. Tables 2 - 4 indicate the
questions posed to students to ascertain their knowledge,
skills and attitude towards victims of violence. A mean
knowledge score of 2.44±0.92 was obtained from 5
knowledge statements. A mean attitude score of 4.0±1.6 was obtained from a maximum
of 7 statements, while a mean confidence score of 4.9±1.5 was recorded from 6. The
maximum obtainable competence (skills) score was 21, and a
mean attitude score of 12.2±3.2 was obtained.

Using the 75th percentile as the cut-off for respondent scores,
60.7% (51) were knowledgeable on VAW, 47.6% (40) were very
confident, 25% (21) had a positive attitude to managing victims
of VAW, and 40.5% (34) were skilled in the management of
victims.

Older students were 5 times more likely to be
knowledgeable (aOR 4.89; p=0.003)
and to have better attitudes (aOR 4.55; p=0.008) towards victims of
violence. Male students had more knowledge of VAW, and female
students had better attitudes to victims. Students who
reported prior training on violence were more likely to have
adequate knowledge (aOR1.64; p=0.33),
and better attitudes (aOR 1.38; p=0.53)
and skills to manage victims (aOR 1.26; p=0.59).

Suggestion to improve knowledge and skills

Student opinions were sought on how to improve their knowledge
and skills on case management relating to VAW. Their responses
included that the topic should be taught or included in the
curriculum (25.7%); dealt with in teaching practice (17.9%) and
addressed through case demonstrations (11%). A summary of the
student suggestions is provided in Table 5.

Training/teaching received on VAW

Thirty-nine student respondents (46.4%) received some formal
training in VAW. Nearly 31% (12) received their teaching at
medical school. Other sources were the church, parents and
electronic media. Most (58.3%) teaching was in the final year of
medical school, and was primarily offered by teachers from the
Departments of Public Health; Obstetrics and Gynaecology; and
Psychiatry. Teaching was mostly delivered as didactic lectures
(83.3%) by doctors (66.7%) and social workers (16.7%).
Interviews with faculty members (see Table 6) revealed an
absence of teaching about VAW in their formal programme.

Of the 39 respondents who received formal training on VAW,
20.5% had training on how to detect warning signs and symptoms,
25.6% could take history on VAW incidents, 25.6% could examine
victims, 33.3% could provide treatment or medical care to
victims, and 28.2% could provide counselling to perpetrators.
Most (51.2 - 64.1%) respondents stated that they would like
these issues addressed in their teaching curriculum. Reasons for
the non-inclusion of VAW in the curriculum and faculty’s view on
their expertise in training on the topic were captured in
interviews with the departmental representatives and indicated
in Table 6. Most of the interviewees admitted to not having had
previous formal training on VAW.

Discussion

Although students demonstrated satisfactory knowledge of
signs and symptoms, they lacked knowledge of the types of VAW.
Their knowledge was best on physical and sexual violence, with
psychological and economic aspects less known. Knowledge
levels of the cohort might have been lower, as
non-participation by some might have been due to a perceived
lack of knowledge. Previous studies that assessed knowledge
and perceptions of medical students were conducted
predominantly in developed contexts10 and
highlighted the value of exposing and training students on a
VAW programme. Studies have also expressed concern over
inadequate training on intimate partner violence.14

In the present study, men surprisingly demonstrated better
knowledge of VAW which might have been due to their increased
exposure or that some might have been perpetrators of VAW. Older
respondents, probably owing to their more extensive life
experiences, and those who had been trained, also demonstrated
better knowledge. This improved knowledge should ultimately
translate into improved attitudes, screening procedures and case
management during clinical practice.

Many students had an accurate estimation of the magnitude of
VAW in society and correctly perceived it their duty to ask
patients about violence. Some were, however, not sympathetic
towards women who chose to remain in violent relationships, and
even expressed the view that such an abused victim then deserved
the experience. This perception is similar to that of nurses in
a study in rural South Africa.15 Research has indicated
that some of these incorrect perceptions could still be
challenged and changed during training.10 Females empathised better
with victims, possibly owing to knowledge of friends, family,
neighbours or themselves being in similar situations. This
aspect was, however, not explored in this study.

Most students admitted to having
limited skills in managing victims of violence, which we suggest
probably reflects the lack of training in this issue. The
results suggest the need for an integrated institutional
curriculum on VAW. This need was confirmed in the interviews
with faculty who reiterated a commitment to include education
about VAW; some reported sporadic teaching even in the absence
of a formal curriculum. Some departments were aware of the need
to review their curricula. Most faculty members interviewed
further acknowledged a need for personal training on VAW, and
agreed to institute training for students. It was felt that an
effective training programme would promote student learning and
expedite professional and personal development.

Two limitations to the study need noting. Firstly, students
might have gained prior knowedge on VAW from sources outside the
school; and secondly, the expertise of tutors and students on
women’s issues in public health might have confounded some of
the observed associations. Similarly, the academic abilities of
the students might have influenced the results. However, these
are likely to affect knowledge and not skills. Nevertheless, the
results still show the need to improve current teaching on the
topic.

Conclusion

While most students were willing and considered it their duty
to ask patients about abuse, they lacked the fundamental
knowledge and skills to do so effectively. This study affirmed
the need for both faculty and students to be trained on issues
relating to VAW, and to receive skills and awareness training on
how to screen patients, which may include an institutional plan
or protocols for routine screening and dealing with emergencies.
There is also a need for a faculty policy to integrate these
efforts. The results from this study serve as a basis for
reviewing the curriculum and enlisting currently committed
members of faculty to enhance and improve students’ knowledge,
skills and attitudes on this important topic.

References

1. Committee
on the Elimination of Discrimination Against Women. Report
of the Committee on the Elimination of Discrimination
Against Women. New York: United Nations General Assembly,
55th Session, 2000.

1. Committee
on the Elimination of Discrimination Against Women. Report
of the Committee on the Elimination of Discrimination
Against Women. New York: United Nations General Assembly,
55th Session, 2000.